Family caregivers of people with dementia can experience loss and grief before death. We hypothesized that modifiable factors indicating preparation for end of life are associated with lower pre-death grief in caregivers.

Cross-sectional.

Caregivers of people with dementia living at home or in a care home.

In total, 150 caregivers, 77% female, mean age 63.0 (SD = 12.1). Participants cared for people with mild (25%), moderate (43%), or severe dementia (32%).

Primary outcome: Marwit-Meuser Caregiver Grief Inventory Short Form (MMCGI-SF). We included five factors reflecting preparation for end of life: (1) knowledge of dementia, (2) social support, (3) feeling supported by healthcare providers, (4) formalized end of life documents, and (5) end-of-life discussions with the person with dementia. We used multiple regression to assess associations between pre-death grief and preparation for end of life while controlling for confounders. We repeated this analysis with MMCGI-SF subscales (“personal sacrifice burden”; “heartfelt sadness”; “worry and felt isolation”).

Only one hypothesized factor (reduced social support) was strongly associated with higher grief intensity along with the confounders of female gender, spouse, or adult child relationship type and reduced relationship closeness. In exploratory analyses of MMCGI-SF subscales, one additional hypothesized factor was statistically significant; higher dementia knowledge was associated with lower “heartfelt sadness.”

We found limited support for our hypothesis. Future research may benefit from exploring strategies for enhancing caregivers’ social support and networks as well as the effectiveness of educational interventions about the progression of dementia (ClinicalTrials.gov ID: NCT03332979).

To conceptualize a “good end of life” for people with dementia from the perspectives of bereaved family caregivers in Japan.

A qualitative study using in-depth, semi-structured interviews focused on the family caregivers’ perceptions of their loved one’s experiences. Family caregivers who had lost their relatives with dementia more than six months previously were recruited using maximum variation sampling by cultural subpopulation. A thematic analysis was conducted.

From 30 interviews held, four main themes emerged. A good end of life for people with dementia means experiencing a “Peaceful Death” while “Maintaining Personhood” at a “Preferred Place” allowing for feelings of “Life Satisfaction.” A “Preferred Place” emerged as a basic requirement to achieving a good end of life according to the three other themes, in particular, “Maintaining Personhood.” However, the interviewees experienced difficulties in ensuring that their loved ones stayed at a “Preferred Place.”

Despite different cultural backgrounds, perceptions of a good end of life with dementia were remarkably similar between Japan and Western countries. However, recent societal changes in family structures and long-term care access in Japan may explain the theme of a comfortable place taking a central position. We suggest that these themes be considered and translated into care goals. They could supplement established end-of-life care goals for quality of life in dementia, which aim to maximize functioning and increase comfort.

Ethics Committee of the Graduate School and Faculty of Medicine, Kyoto University (R0808-2)

The authors assessed the association of physical function, social variables, functional status, and psychiatric co-morbidity with cognitive function among older HIV-infected adults.

From 2012–2014, a cross-sectional study was conducted among HIV-infected patients ages 50 or older who underwent comprehensive clinical geriatric assessment.

Two San Francisco HIV clinics.

359 HIV-infected patients age 50 years or older

Unadjusted and adjusted Poisson regression measured prevalence ratios and 95% confidence intervals for demographic, functional and psychiatric variables and their association with cognitive impairment using a Montreal Cognitive Assessment (MoCA) score < 26 as reflective of cognitive impairment.

Thirty-four percent of participants had a MoCA score of < 26. In unadjusted analyses, the following variables were significantly associated with an abnormal MoCA score: born female, not identifying as homosexual, non-white race, high school or less educational attainment, annual income < $10,000, tobacco use, slower gait speed, reported problems with balance, and poor social support. In subsequent adjusted analysis, the following variables were significantly associated with an abnormal MoCA score: not identifying as homosexual, non-white race, longer 4-meter walk time, and poor social support. Psychiatric symptoms of depressive, anxiety, and post-traumatic stress disorders did not correlate with abnormal MoCA scores.

Cognitive impairment remains common in older HIV-infected patients. Counter to expectations, co-morbid psychiatric symptoms were not associated with cognitive impairment, suggesting that cognitive impairment in this sample may be due to neurocognitive disorders, not due to other psychiatric illness. The other conditions associated with cognitive impairment in this sample may warrant separate clinical and social interventions to optimize patient outcomes.

In response to the global challenges of population aging in the World, it is crucial to improve research, education and clinical training in old age in order to meet the growing demands placed on psychogeriatric care services.

An overview is provided on the status of old age psychology and psychiatry, and other health professionals, as part of the multidisciplinary care delivery system for the elderly in the World. Available educational offerings and clinical training in geriatric mental health and geriatrics at both undergraduate and postgraduate level are described.

Important issues raised include the need for more educational and clinical training programs for specialists, a broader commitment to aging research and the need to increase interest in working with older adults among students across disciplines at the medical, psychological and education faculties and hospitals.

This educational initiative must focus not only on the transmission of knowledge on aging-related topics, but also on the training of specific skills and competencies.

An effective intervention in psychogeriatrics should involve a strategy with the participation of a multidimensional network that includes the commitment of researchers, educators, clinicians, health policy-makers and older adults.

Several recommendations to improve educational strategies concerning late life mental health care are presented to promote discussion, and develop new educational strategies.

Horácio Firmino – Advances at educational at the curriculum of the new Psychiatrists and other mental health professionals at Portugal

Carlos A. de Mendonça Lima- The WPA survey on Teaching and Training in Old Age Psychiatry: 2001-2018

Manuel Sanchez Perez – Mental Health Educational Reality at Spain

Manuel Teixeira Verissimo – Geriatrics New or Old discipline- educational perspectives of Europe and the reality of Portugal

Depression often coexists with other chronic conditions in older people. The COACH study is an ongoing random controlled trial (RCT) to test the effectiveness of a primary-care-based collaborative care approach to treat co-morbid hypertension and depression in Chinese rural elders. In the COACH model, a team—village doctor (VD), aging worker (AW), and psychiatrist consultant—provides collaborative care to enrolled subjects in each intervention village for 12 months. This study examines how COACH was implemented and identifies facilitators and barriers for its more widespread implementation.

Five focus groups were conducted, two with VDs, two with AWs, and one with psychiatrists, for a total of 38 participants. Transcripts were analyzed using qualitative content analysis.

COACH care-team members showed shared understanding and appreciation of the team approach and integrated management of hypertension and depression. Team collaboration was smooth. All members regarded COACH to be effective in reducing depressive symptoms and improving patient health. Facilitators to implementation include training, leaders’ support, geographic proximity between VD and AW pairs, preexisting relationships among care-team members, comparability of COACH activities and existing practices of VDs and AWs, and care team members’ caring about older members of their villages. Barriers to sustainability include frustration of some VDs related to their low wages and feelings of overload of some AWs.

COACH was positively perceived and successfully implemented. The findings offer guidance for planning primary-care-based collaborative depression care in low- and middle-income countries.

To use a Machine Learning (ML) approach to compare Neuropsychiatric Symptoms (NPS) in participants of a longitudinal study who developed dementia and those who did not.

Mann-Whitney U and ML analysis. Nine ML algorithms were evaluated using a 10-fold stratified validation procedure. Performance metrics (accuracy, recall, F-1 score, and Cohen’s kappa) were computed for each algorithm, and graphic metrics (ROC and precision-recall curves) and features analysis were computed for the best-performing algorithm.

Primary care health centers.

128 participants: 78 cognitively unimpaired and 50 with MCI.

Diagnosis at baseline, months from the baseline assessment until the 3rd follow-up or development of dementia, gender, age, Charlson Comorbidity Index, Neuropsychiatric Inventory-Questionnaire (NPI-Q) individual items, NPI-Q total severity, and total stress score and Geriatric Depression Scale-15 items (GDS-15) total score.

30 participants developed dementia, while 98 did not. Most of the participants who developed dementia were diagnosed at baseline with amnestic multidomain MCI. The Random Forest Plot model provided the metrics that best predicted conversion to dementia (e.g. accuracy=.88, F1=.67, and Cohen’s kappa=.63). The algorithm indicated the importance of the metrics, in the following (decreasing) order: months from first assessment, age, the diagnostic group at baseline, total NPI-Q severity score, total NPI-Q stress score, and GDS-15 total score.

ML is a valuable technique for detecting the risk of conversion to dementia in MCI patients. Some NPS proxies, including NPI-Q total severity score, NPI-Q total stress score, and GDS-15 total score, were deemed as the most important variables for predicting conversion, adding further support to the hypothesis that some NPS are associated with a higher risk of dementia in MCI.

To study the influence of cognitive reserve (CR) on cognitive performance of individuals with subjective cognitive complaints (SCCs) within a period of 36 months.

We used a general linear model repeated measures procedure to analyze the differences in performance between three assessments. We used a longitudinal structural equation modeling to analyze the relationship between CR and cognitive performance at baseline and at two follow-up assessments.

Participants with SCCs were recruited and assessed in primary care health centers.

A total of 212 participants older than 50 years with SCCs.

Cognitive reserve data were collected with an ad hoc questionnaire administered to the subjects in an interview. General cognitive performance (GCP), episodic memory (EM), and working memory (WM) have been evaluated. The Mini-Mental State Examination and the total score of Spanish version of the Cambridge Cognitive Examination evaluated the GCP. Episodic memory was assessed with the Spanish version of the California Verbal Learning. Working memory was evaluated by the counting span task and the listening span task.

The satisfactory fit of the proposed model confirmed the direct effects of CR on WM and GCP at baseline, as well as indirect effects on EM and WM at first and second follow-up. Indirect effects of CR on other cognitive constructs via WM were observed over time.

The proposed model is useful for measuring the influence of CR on cognitive performance over time. Cognitive response acquired throughout life may influence cognitive performance in old age and prevent cognitive deterioration, thus increasing processing resources via WM.

To identify, in caregivers of patients with Alzheimer’s disease (AD) dementia, factors associated with subjective (personal, physical, emotional, and social) and objective (informal caregiver time and costs) caregiver burden.

Prospective longitudinal European observational study: post-hoc analysis.

Clinic.

Community-dwelling patients in France and Germany aged ≥ 55 years (n = 969) with probable AD and their informal caregivers.

Mini-Mental State Examination (MMSE), Alzheimer’s Disease Cooperative Study—Activities of Daily Living (ADCS-ADL), 12-item Neuropsychiatric Inventory (NPI-12), Zarit Burden Interview (ZBI), informal caregiver basic and instrumental ADL hours (Resource Utilization in Dementia instrument), and informal caregiver costs. Mixed-effect models of repeated measures (MMRM) were run, including baseline and time-dependent covariates (change from baseline [CFB] to 18 months in MMSE, ADCS-ADL, and NPI-12 scores) associated with CFB in ZBI score/informal caregiver time over 36 months (analyzed using linear regression models) and informal caregiver costs over 36 months (analyzed using generalized linear models).

Greater decline in patient function (ADCS-ADL) over 18 months was associated with increased subjective caregiver burden (ZBI), hours, and costs over 36 months. Increased behavioral problems (NPI-12) over 18 months also negatively impacted ZBI. Cognitive decline (MMSE) over 18 months did not affect change in caregiver burden.

Long-term informal caregiver burden was driven by worsening functional abilities and behavioral symptoms but not cognitive decline, over 18 months in community-dwelling patients with AD dementia. Identifying the drivers of caregiver burden could highlight areas in which interventions may benefit both caregivers and patients.

1) Sytse Zuidema: The RID (Reduction of inappropriate psychotropic drugs in dementia) study Nursing home residents with dementia and neuropsychiatric symptoms are prescribed psychotropic drugs too often and also sometimes inappropriate. Multidisciplinary interventions can help to facilitate better care by using psychosocial interventions and help to decrease inappropriate psychotropic drug use. We supported implementation of such interventions through participatory action research, to facilitate nursing homes to design, and implement their own local interventions. The results of the RCT (including a process evaluation) will be presented.

2) Tzung-Jeng Hwang: dextromethorphan for treating agitation

Agitation is highly prevalent in patients with dementia and associated with significant impairment of quality of life, early institutionalization, and higher mortality. Although no pharmacotherapy has been approved by the US FDA for dementia patients with agitation, off-label use of antipsychotic agents is common. But antipsychotic agents are clearly associated with increased adverse effects, including stroke and death. Dextromethorphan (DXM) is a low-affinity uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist, a high-affinity sigma-1 receptor agonist, a serotonin and norepinephrine reuptake inhibitor, and a nicotinicα3β4 receptor antagonist. The combination of DXM and low dose quinidine (Q) has been approved for the treatment of pseudobulbar affect in 2010. A recent study found that DXM/Q may be effective for the management of agitation in patients with Alzheimer disease (AD). In this talk, a pilot study on using DXM alone to treat agitation in dementia will be reported. Overall, the use of DXM 60-240 mg/day resulted in a high proportion of improvement (CGI-agitation: 69% much improved, 25% minimally improved). No severe adverse events were found. The results support DXM may be efficacious and safe.

3) Marie Andree Bruneau: OPUS-AP

OPUS-AP aims at improving resident care through increased staff’s knowledge and competency, resident-centered approaches, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. OPUS-AP is implemented through integrated knowledge translation and mobilization activities. Antipsychotic, benzodiazepine, antidepressant prescriptions and BPSD were evaluated every 3 months for 9 months. Phase 2 of OPUS-AP was conducted in 129 LTC centres in Quebec, Canada, from April to December 2019. At baseline (April 2019), 10,601 residents were admitted on OPUS-AP participating wards from which 74% had a diagnosis of major neurocognitive disorder (MNCD) and 47% an antipsychotic prescription. The follow-up cohort included 4,087 residents with both MNCD and antipsychotic prescription. Among the 1381 residents in whom antipsychotic deprescribing was attempted between baseline and 9 months and still included at 9 months, successful deprescribing was achieved in 79,2% (cessation 44,8% or dose decrease 34,5%)). No increase in benzodiazepine or antidepressant prescriptions nor worsening of BPSD were observed.

1) Kathrin Schmuedderich: Severe agitation and quality of life

A secondary data analysis was performed on the relationships between the severity of agitation (NPI-Q) and the single dimensions of quality of life (QUALIDEM) in people with dementia living in German nursing homes. In order to determine the differences between people with severe agitation and the group of people with mild or no agitation, a matching method and regression analyses were used. The findings show that severe agitation is related to lower quality of life in five out of six dimensions of quality of life.

2) Wai-chi Chan: BPSD as a predictor of cognitive decline

Description will follow

3) Huali Wang: Challenging behavior in China

Description will follow

1) Wendy Moyle: Measurement of agitation

This presentation demonstrates how the use of video observation/coding, standardised measures of agitation (CMAI-SF), and physiological measures (actigraphy) produced different outcome results related to agitated behaviours following the introduction of a social robot. When measuring agitation, we need to consider using different types of measures to ensure data reliability and validity and longitudinal research methods to identify efficacy of psychosocial interventions and effective measurement of agitation when using social robots.

2) Discussion on measurement of agitation, discussing and making plans for datasharing based on a template for datastructures

1) Rob Kok: short intro on ECT in BPSD

The majority of patients with dementia develop agitation or aggression in the course of their disease. In some severe cases, pharmacological and other interventions are not effective in improving these symptoms. A recent systematic review suggested that electroconvulsive therapy (ECT) could be an effective treatment for severe and treatment-refractory agitation and aggression in dementia, with few adverse consequences. We need to have controlled studies, address the stigma of ECT and develop professional guidelines for the application of ECT for agitation and aggression in dementia, particularly because most patients are not able to provide informed consent.

2) Discussion and making plan for international survey on application of ECT in BPSD

We examined race differences in the DSM-IV clinical significance criterion (CSC), an indicator of depressive role impairment, and its impact on assessment outcomes in older white and black women with diagnosed and subthreshold depression.

We conducted a secondary analysis of a community-based interview study, using group comparisons and logistic regression.

Lower-income neighborhoods in a Midwestern city.

411 community-dwelling depressed and non-depressed women ≥ 65 years (45.3% Black; mean age = 75.2, SD = 7.2) recruited through census tract-based telephone screening.

SCID interview for DSM-IV to assess major depression and dysthymia; Center for Epidemiologic Studies-Depression Scale to define subthreshold depression (≥16 points); Mini-Mental State Examination, count of medical conditions, activities of daily living, and mental health treatment to assess health factors.

Black participants were less likely than Whites to endorse the CSC (11.8% vs. 24.1%; p = .002). There were few race differences in depressive symptom type, severity, or count. Blacks with subthreshold depression endorsed more symptoms, though this comparison was not significant after adjustments. Health factors did not account for race differences in CSC endorsement. Disregarding the CSC-eliminated differences in diagnosis rate, race was a significant predictor of CSC endorsement in a logistic regression.

Race differences in CSC endorsement are not due to depressive symptom presentations or health factors. The use of the CSC may lead to underdiagnosis of depression among black older adults. Subthreshold depression among Blacks may be more severe compared to Whites, thus requiring tailored assessment and treatment approaches.

Recently, there has been a growing interest in examining forms of illness-related resilience. This study examines associations between lifestyle behavioral factors and multimorbidity resilience (MR) among older adults.

Using baseline data from the Comprehensive Cohort of the Canadian Longitudinal Study on Aging, we studied 6,771 Canadian adults aged 65 or older who reported two or more of 27 chronic conditions, and three multimorbidity clusters: cardiovascular/metabolic, osteo-related, and mental health. Associations were explored using hierarchical linear regression modeling, controlling for sociodemographic, social/environmental, and illness context covariates.

Among older adults with two or more illnesses, as well as the cardiovascular/metabolic and osteo-related illness clusters, having a non-obese body mass, being a non-smoker, satisfaction with quality of sleep, having a good appetite, and not skipping meals are associated with MR. However, the mental-health cluster resulted in different behavioral lifestyle associations, where MR was not associated with obesity, smoking, or appetite, but inactivity demonstrated moderate positive associations with MR.

While there are similar patterns of lifestyle behaviors across multimorbidity and multimorbidity clusters involving physiological chronic illnesses, those associated with mental health are distinct. The results have implications for healthy aging among persons coping with multimorbidity.